OUTCOME OF THROMBOLYTIC THERAPY IN RELATION TO HOSPITAL SIZE AND INVASIVE CARDIAC SERVICES

Objective: The outcome of patients with acute myocardial infarction who received thrombolytic therapy was assessed in relation to the size and comprehensiveness of cardiovascular services in the admitting hospitals. Methods: Two characteristics were obtained for each of the 438 hospitals: number of beds and in-house availability of cardiovascular services (coronary catheterization laboratory and coronary angioplasty or bypass surgery). Hospitals were grouped into four categories on the basis of size (less than or equal to 300 vs >300 beds) and availability of cardiovascular services. Baseline and outcome variables were compared by chi(2) analysis and logistic regression. Patients were followed up for 6 months. Results: Baseline variables were comparable among hospital categories except for significant differences in the distribution of antecedent angina and time to treatment. Significantly more coronary angioplasties and bypass surgeries were performed in patients first treated in hospitals with coronary revascularization services (4.1% and 4.2% vs 1.0% and 1.9%, P<.0001). Rates of strokes (1.9% vs 1.3% and 1.6%, P=.54), hos pital mortality (11.9% vs 8.5%, (P=.11), and 6-month mortality (17.0% vs 11.8% and 12.3%, P=.03) were highest among patients treated in small hospitals that had coronary revascularization facilities. The rate of invasive procedures was higher in the smaller hospitals (odds ratio [OR], 1.44; 95% confidence limits [CL], 1.11 and 1.87; P=.006) and in hospitals with coronary revascularization services (OR, 4.05; 95% CL, 3.14 and 5.22; P<.0001); hemorrhage was more frequent in centers with coronary revascularization facilities (OR, 1.39; 95% CL, 1.13 and 1.71; P=.002). Rates of hospital mortality and 6-month mortality were similar. Conclusions: Patients with acute myocardial infarction treated with thrombolytic therapy have the same mortality in small centers without in-house coronary revascularization services as in larger centers with such services.